Desensitization

Desensitization is an anxiety-reducing strategy involving exposure to the feared object or situation.  Initially the patient needs to be assessed as being an appropriate candidate for desensitization techniques.  Desensitization can be done both in imagination and in vivo and the combination of both procedures leads to the most effective outcome.  In order to provide desensitization treatment effectively to patients, it is necessary to develop a case formulation and treatment plan; this includes assessing: presenting problems and history; functional or dysfunctional belief systems; triggers and problem context, including aggravating and ameliorating factors; the patient’s pre-treatment coping strategies both adaptive and maladaptive; and the patient’s salient learning experiences. It is important to develop with the patient a series of treatment goals and interventions as well as identifying treatment obstacles and potential solutions to these obstacles.  Issues that need to be dealt with prior to desensitization include the patient’s underlying beliefs and beliefs about recovery as well as having an adaptive home/work adherence program.  It is critical to assess trauma-related anger, shame and guilt, as well as the patient’s sense of responsibility, both pre- and post-incident.

Often there is a concomitant diagnosis of depression; whereas the treatment for both may coincide, and some patients may experience trauma symptoms that are treatable in conjunction with the depressive episode, for many the symptoms are interlocking, and not treating the depression before using desensitization can lead to further regression.  Therefore, in some cases, desensitization may be used without formally introducing it as such, enabling the patient to benefit from the process without risking decompensation.

Once these initial items are assessed then a hierarchy needs to be constructed in order to perform the desensitization process in the most effective manner.  Anxiety hierarchy development is a critical step in desensitization; if the hierarchy is not appropriately established and assessed during the course of treatment, then this procedure may not be effective in ameliorating the anxiety responses that are its target.

In addition, during the initial psychological assessment it is necessary to tailor the treatment plan for the individual patient, evaluating the safety of the patient in performing the exercises described in the anxiety hierarchy; evaluating the types and severity of functional impairments, which include not only the situation in question but also the entire psychosocial framework of the patient; establishing goals of treatment; monitoring the patient’s psychological status; and providing education to the patient and when appropriate, to the family as well.  It is also important to develop techniques to enhance treatment adherence and to work with the patient to address early signs of relapse.

During the desensitization paradigm itself, it is important to assess regularly exposure duration and intensity, hierarchic versus non-hierarchic approaches, as well as adding cognitive restructuring to the desensitization paradigm.  Cognitive restructuring can include coping self statements, behavorial contracting, post-exposure processing, as well as interpersonal skills training.  Interventions for the final stages of treatment include treatment tapering, maintaining and extending treatment gains, as well as helping the patient deal with lapses and relapses.

Once these issues have been identified then systematic desensitization/in vivo desensitization can be undertaken with constant evaluation of each step along the way. The range within which desensitization techniques can be effective varies greatly by individual and there is no way to predict at the outset of treatment the patient’s ability to perform the desensitization procedure and to benefit from its implementation.